Giant Urethral Diverticulum: A Novel Approach To Repair

Abstract

Urethral diverticula are often missed and are difficult to repair, with a reported postoperative recurrence rate of 15% to 35%, which increases with subsequent attempts at repair. We report the successful repair of a giant horseshoe-shaped urethral diverticulum using a combined anterior vaginal and suprameatal approach and porcine dermal grafting. CASE REPORT A 40-year-old woman with myasthenia gravis was referred to our department with gross continuous urinary incontinence, frequency and urinary tract infection. Three months previously she had undergone unsuccessful repair of a urethral diverticulum at another institution. Prior to that procedure there had been no history of urinary incontinence. Assessment included voiding cystourethrogram (fig. 1) and cystourethroscopy. Cystourethroscopy revealed a 2 cm. opening on the right lateral wall of the mid urethra, which remained full of contrast medium after voiding. This large fluid filled diverticulum explained the severe and persistent incontinence. Urodynamic studies ruled out concomitant stress urinary incontinence. With the patient under epidural anesthesia, the diverticulum was accessed via an anterior vaginal wall flap based superiorly. Gross examination revealed a large horseshoe-shaped diverticulum with the curve of the horseshoe lying anterior to the urethra. For this reason an incision was made supra-urethrally to facilitate access to the anterior horseshoe and the large urethral defect. The entire diverticulum was excised, and the urethral defect was closed with 4-zero catgut sutures. The urethra was double wrapped in a 2 7 cm. strip of porcine dermal xenograft in an attempt to buttress the mid urethra, a major part of whose circumference was grossly deficient and around which a large dead space existed, which had been occupied previously by the giant diverticulum. The urethral supports were repaired anteriorly. The vaginal incision was closed with an absorbable suture, and a 16Fr silicone catheter was inserted into the bladder and left in situ for 3 weeks. Cystography at 3 weeks showed no extravasation, and the catheter was removed. Symptomatically, the patient was completely dry. At 9 weeks postoperatively repeat voiding cystourethrogram (fig. 2) and cystoscopy were performed. These studies revealed a widened mid urethra with no residual diverticulum or defect. The patient remained completely dry and was pleased with the outcome. DISCUSSION